The economic impact of two-stage knee arthroplasty revisions: a projection for a specialized health center in Türkiye

Abstract

Objectives: The increase in the number of arthroplasty surgeries worldwide also leads to an increase in revision surgeries. This study examines the costs of primary and revision arthroplasty treatments in a tertiary university hospital's orthopedics and traumatology clinic. It also explores the impact of revision surgeries on the healthcare system.

Methods: Seventy-six patients who had total knee arthroplasty at a university hospital between 01.01.2017 and 30.09.2022 were included in the study. The patients were divided into three groups: primary (n=25), aseptic reasons one-stage revision (n=27), and septic reasons two-stage revisions (n=24). For each patient included in the study, detailed documents regarding medical supplies, anesthesia, operating room, intensive care, consultation, medicine/serum, medical treatment, laboratory, blood and blood products, microbiology, radiology, food, bed, and attendant fees were provided separately by the hospital purchasing and statistics departments.

Results: When comparing the costs of primary, one-stage revision, and two-stage revision surgeries, the average costs were 5689 Turkish Lira (₺), 8294.97 ₺, and 40919.67 ₺, respectively. In patients with septic reasons, the group that underwent two-stage revisions had significantly higher costs than the aseptic group in terms of surgery time, hospital stay duration, medication, treatment, surgery, anesthesia, intensive care, laboratory tests, imaging, blood center services, consultations, visits, meal expenses, and invoiced amount (P<0.001).

Conclusion: Preventing and treating periprosthetic infections is costly and challenging. We need more research to develop effective protocols and reduce costs. As the number of patients undergoing knee arthroplasty is expected to rise, healthcare systems must ensure the sustainability of public financial resources, especially in public university hospitals.

Keywords

• Arthroplasty
• knee replacement
• revision
• cost analysis
• hospital economics

References

1. 1. Long H, Liu Q, Yin H, et al. Prevalence Trends of Site-Specific Osteoarthritis From 1990 to 2019: Findings From the Global Burden of Disease Study 2019. Arthritis Rheumatol. 2022;74(7):1172-1183. doi: 10.1002/art.42089.
2. 2. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27(8 Suppl):61-65.e1. doi: 10.1016/j.arth.2012.02.022.
3. 3. Klug A, Gramlich Y, Rudert M, et al. The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years. Knee Surg Sports Traumatol Arthrosc. 2021;29(10):3287-3298. doi: 10.1007/s00167-020-06154-7.
4. 4. Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev. 2014;27(2):302-345. doi: 10.1128/CMR.00111-13.
5. 5. Gbejuade HO, Lovering AM, Webb JC. The role of microbial biofilms in prosthetic joint infections. Acta Orthop. 2015;86(2):147-158. doi: 10.3109/17453674.2014.966290.
6. 6. Leonard HA, Liddle AD, Burke O, Murray DW, Pandit H. Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Relat Res. 2014;472(3):1036-1042. doi: 10.1007/s11999-013-3294-y.
7. 7. Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89 Suppl 3:144-151. doi: 10.2106/JBJS.G.00587.
8. 8. Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: meta-analysis. Int Orthop. 2011;35(2):253-260. doi: 10.1007/s00264-010-1144-z.

9. 9. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23(4):183-189. doi: 10.1086/502033.
10. 10. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23(7):984-991. doi: 10.1016/j.arth.2007.10.017.
11. 11. Parvizi J, Pawasarat IM, Azzam KA, Joshi A, Hansen EN, Bozic KJ. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplasty. 2010;25(6 Suppl):103-107. doi: 10.1016/j.arth.2010.04.011.
12. 12. Bonnin M, Deschamps G, Neyret P, Chambat P. [Revision in non-infected total knee arthroplasty: an analysis of 69 consecutive cases]. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(7):694-706. [Article in French].
13. 13. Sousa R, Ribau A, Alfaro P, et al. The European Bone and Joint Infection Society definition of periprosthetic joint infection is meaningful in clinical practice: a multicentric validation study with comparison with previous definitions. Acta Orthop. 2023;94:8-18. doi: 10.2340/17453674.2023.5670.
14. 14. Barret M WE, Whalen D. Summary 2007 HCUP Nationwide Inpatient Sample (NIS) Comparison Report. HCUP Method Series Report # 2010-03. Online September 9, 2010. U.S. Agency for Healthcare Research and Quality.
15. 15. Ollenschläger G. Assuring the Quality of Health Care in the EU: Germany. In book: Assuring the Quality of Health Care in the European Union. A case for action. Ed.: European Observatory Studies Series Nr 12, WHO Publication: Copenhagen, 2008: pp. 116-120.
16. 16. Mark Allen Group. Hospital non-compliance risking joint patient safety. Br J Hosp Med. 2012;73(10):548. doi: 10.12968/hmed.2012.73.10.548a.
17. 17. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87(8):1746-1751. doi: 10.2106/JBJS.D.02937.
18. 18. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996;(331):140-145. doi: 10.1097/00003086-199610000-00019.
19. 19. Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty. 2014;29(5):929-932. doi: 10.1016/j.arth.2013.09.017.
20. 20. Kapadia BH, Banerjee S, Cherian JJ, Bozic KJ, Mont MA. The Economic Impact of Periprosthetic Infections After Total Hip Arthroplasty at a Specialized Tertiary-Care Center. J Arthroplasty. 2016;31(7):1422-1426. doi: 10.1016/j.arth.2016.01.021.
21. 21. Dırvar F, Dırvar SU, Yıldırım T, Cengiz Ö, Talmaç MA. Cost Analysis in Knee Revision Arthroplasty: A Study at the Research and Training Hospital in Turkey. JAREM J Acad Res Med. 2020;10(2):133-137. doi: 10.4274/jarem.galenos.2020.2767.
22. 22. Kasch R, Merk S, Assmann G, et al. Comparative Analysis of Direct Hospital Care Costs between Aseptic and Two-Stage Septic Knee Revision. PLoS One. 2017;12(1):e0169558. doi: 10.1371/journal.pone.0169558.
23. 23. Vertullo CJ, Graves SE, Peng Y, Lewis PL. An optimum prosthesis combination of low-risk total knee arthroplasty options in all five primary categories of design results in a 60% reduction in revision risk: a registry analysis of 482,373 prostheses. Knee Surg Sports Traumatol Arthrosc. 2019;27(5):1418-1426. doi: 10.1007/s00167-018-5115-z.
24. 24. Adie S, Harris I, Chuan A, Lewis P, Naylor JM. Selecting and optimising patients for total knee arthroplasty. Med J Aust. 2019;210(3):135-141. doi: 10.5694/mja2.12109.
25. 25. Okafor C, Hodgkinson B, Nghiem S, Vertullo C, Byrnes J. Cost of septic and aseptic revision total knee arthroplasty: a systematic review. BMC Musculoskelet Disord. 2021;22(1):706. doi: 10.1186/s12891-021-04597-8.
26. 26. Ashkenazi I, Christensen T, Ward SA, et al. Trends in Revenue and Cost for Revision Total Knee Arthroplasty. J Arthroplasty. 2023;38(7 Suppl 2):S97-S102. doi: 10.1016/j.arth.2023.01.041.
27. 27. Lopez-Villegas A, Bautista-Mesa RJ, Acosta-Robles P, et al. Analysis of Healthcare Costs Incurred in Regional Hospitals in Andalusia (Spain) during the COVID-19 Pandemic. Int J Environ Res Public Health. 2022;19(23):16132. doi: 10.3390/ijerph192316132.